A dichotomous approach to
Mental Health
Héðinn Unnsteinsson
Mental Health Policy expert with the Icelandic Ministry of Health
Former Technical Officer with MH Programme of WHO-EURO
WHO am I?
•
Héðinn Unnsteinsson
–
–
–
–
–
–
–
–
–
–
First experience of manic-depression during medical
studies in 1991
Held in hospital, diagnosed and medicated in 1994
Advocate and a lobbist in a user NGO from 1995Graduated with two University degrees in education in 1996
& 1999
Started the icelandic mental health promotion project
(Geðrækt) in 2000 and ran it until 2002
Graduated with a M.Sc in International Policy Analysis
from the Univ. of Bath in 2003
Internship with WHO HQ in 2003
Technical Officer with the MH program of WHO-EURO
since march 2004-jan 2007
Part time lecturer with the Public Health Dep of the
University of Reykjavik and with the PHD of the
University of Iceland
A mental health policy expert with the Icelandic Ministry
of Health
2
Set up
1.
2.
3.
4.
5.
6.
7.
The duality & conceptuality of mental health
The burden of mental health problems
The Helsinki documents
Trends of change; users in Europe and the
Transformation Process
The Horizontal ideology
Inclusion of Civil Society (ICS)
Conclusion in Norway
3
The duality & conceptuality of mental
health/mental ill health
Conceptuality
Historical Madness becomes a mental health problem
• Madness -> Mental illness -> Mental
health problem
• Dichotomy & Dualism
– Hygieia (social, causal)
– Asclepius (medical, consequential)
• Ship of fools
– Foucault
5
6
Mad-his-Story
• Quakers in Philadelphia 1840-70
– Empathy, compassion, humanism
• Social Eugenics 1920-1940
– Francis Galton
• ‘Kantian’ science of mental illness 1900– somatic and psychotropic emphasis
– Insulin coma
– Electroshocks
– Frontal-Lobotomy
– Sterilisations
– Closed wards-forced treatment
– Neuroleptic drugs (Thaorazine, Haldol)
– SSRI antidepressant
7
8
9
The dichotomy of health in modern
times
HYGIEA VS. ASCLEPIUS
A social approach to health aims to
preserve health by considering the
way of life, while the medical
approach restores health by
treatment of dis-ease
(McKeowan, 1979)
The Medical
Model
The Social Model
‘Dis-ease’
‘Ease’
Asclepius
Hygieia
Medicalisation
Health Promotion
Natural science
Social Science
Mental ill health
Mental health
Individual
Collective
11
Mynd 1.
The illness system
The health system
Treatment
Rehabilitation
Early
Intervention
Illness
Prevention
Promotion
Health
Héðinn Unnsteinsson
12
Lessons from history
• “ As we in the 21st century shake our
heads over the methods that were used
to “cure” mental disorders 50-100 years
ago; as will our children look back and
shake their heads over some of the
methods and approaches we are using
now”
13
Burden of dis-ease/mental health
problems
“Burden” of dis-ease
• “Burden” caused by psychiatric- and
neurological diseases:
– 19.5% in Europe/ 13% in the World
(DALY’s) (disibility adjusted life years)
– Cause of 39.7% of all disability in Europe
(YLD) (Years lost to disability)
– Estimated that 27% of all Europeans
suffer at any given time from a mental
health problem (EU green paper, 2006)
15
Burden of disease
CAUSES
1. Ischemic heart disease
DALYs %
12.5
2. Unipolar depressive disorders
5.9
3. Cerebrovascular disease
5.5
4. Self-inflicted injuries
4.9
5. Road-traffic accidents
3.1
6. Alcohol-use disorders
2.9
7. Hearing loss, adult onset
2.9
8. Osteoarthritis
2.5
9. Violence
2.3
10. Trachea, bronchus and lung cancer
2.0
16
Neuro-psychiatric conditions
Europe: Years lost to disability
Ranking 1st Unipolar depressive disorders
13.7%
Ranking
2nd
Alcohol use disorders
6.2%
Ranking
7th
Alzheimer and other dementias
3.7%
Ranking
11th
Schizophrenia
2.3%
Ranking
12th
Bipolar disorders
2.2%
17
Total DALYs
Neuropsychiatric
conditions
Total health budget
Mental health budget
18
Treatment Gap
Western Europe
• Psychosis: 17.8%
• Bipolar disorder: 39.9%
• Major depression: 45.4%
• Panic disorder: 47.2%
• Anxiety disorder: 62.3%
• Alcohol dependence: 92.4%
Kohn 2004
19
20
The Helsinki documents
The Helsinki Documents
The WHO/EURO 2005 Mental Health Declartion and Action Plan
for Europe
http://www.euro.who.int/mentalhealth
Pre
• Who contributed:
– WHO/EURO
– European Commission (Commissioner of Health
and Consumer Protection)
– Council of Europe (CoE)
• The declaration was both a new beginning and an
end in itself:
– 30-40 (declarations, resolutions, conclusions etc
CoE, WHO, EU)
• Wide socio-economical dualistic approach (mh vs.
mi)
–
“We believe that the primary aim of mental health activity is to enhance
people’s well-being and functioning by focusing on their strengths and
resources, reinforcing resilience and enhancing protective external
factors” (1.art form preamble of the decl.) (..Alma Ata, Ottawa etc…)
22
Ministerial Conference on Mental
Health in Helsinki
•400 participants
•228 country representatives from 51 Member States
•42 ministerial level
•23 NGOs present
•35 users and carers
23
Priorities for the next decade
• Foster awareness of the importance of mental
wellbeing;
• Empower and support people with mental health
problems to tackle suffering from stigma,
discrimination and inequality;
• Design and implement comprehensive, integrated and
efficient mental health systems that cover promotion,
prevention, care and recovery;
• Address the need for a competent workforce, effective
in all these areas.
24
The Action Plan
• The 12 core action points
– The challenge in every point
• With additional suggestion of actions
• The declaration is in fact the acumilated good intention of
last 30-40 years
• The documents are a mental health paridigm for European
Governments to shape their national mh policies
• Their utility and use is based on something that they
encourage highly:
Cooperation of all concerned =
“The Inclusion of Civil Society” (ICS)
“an horizontal approach”
25
WHO’s 4 Core Objectives:
1) Reducing stigma, promoting mental
well-being and preventing mh
problems
2) Implementing policy and services
delivered by a competent workforce
3) Generating and disseminating
information and research
4) Advocating for user empowerment
26
and human rights
4) Advocating for user empowerment and
human rights
Indicators:
• The ending of inhumane and degrading treatment
and care and the enactment of human rights and
mental health legislation across the Region;
• An increase in level of education and employment
opportunities of people with mental health problems;
• An increase in active grass roots NGOs;
• Representation of users and carers on groups
responsible for planning, delivery, monitoring and
inspection of mental health activities.
27
28
Trends of (slow) change; users in
Europe and the Transformation
Process
Key issues of Users
• Acceptence/Empowerment
• Inclusion/Involvement
–
–
–
–
•
•
•
•
Housing
Employment
Education
Policy
Human Rights
Stigma-Discrimination
Inequality
Treatment & Services
30
•POWER
•AUTHORITY
31
32
33
other key issues…
..users and carers in Europe are talking about
• The right to self determination on treatment and
medication (Autonomy)
• Misuse of psychiatric medication (The link of SSRI
drugs to acts of violence)
• The issue of “neuroleptic” drugs
• Distinction between intellectual & Psychosocial
disabilities
• Cooperation on the Helsinki documents
• The need and desire to be heared and have a role
• Direct payments to users and carers*
34
The STATE or
Municipalities
Direct Payment
PP
A Human Being
and a taxpayer
PP
Hospital
PP
Other Market services
35
From Institution to Community Care
• Diversity in the community (praised in speach,
neglegted in action)
– No research has shown that Hospital care alone or
community care alone is sufficent
– All research promote: Balance of community and hospital
care
• Proportion and nature is determinated by many factors:
– The type of society, culture, methodology,
– User influence, ideology etc., “social firms”
– Our big Institutions have to change.....
• “the biggest institution is usually within ourself ”
36
20th Century Model
Policlinics
Primary Care
Care
Primary
Policlinics
Hospital
Policlinics
Primary Care
37
Service Model 21st Century
Residential
Care
Inclusion and
rehabilitation
Acute
Hospital
Secure
places
CMHTs
Primary
Care
38
Num ber of psychiatric beds in w estern Europe
450
Austria
Belgium
Denmark
Finland
France
Germany
Greece
Iceland
Ireland
Italy
Luxembourg
Netherlands
Norw ay
Portugal
Spain
Sw eden
Sw itzerland
United Kingdom
400
350
250
200
150
100
50
0
02
00
98
96
94
92
90
88
86
84
82
39
80
78
Beds per 100,000
300
Changes
• Mental health is a much broader issues than an medical
one.
• If we want to affect it we have to go for mental health
determinates, its causes, not merely diagnosing a mental
dis-ease and putting on a remedy.
• And to do that we need a much broader approach than
we are seeing now: Therefore: A paradigmal shift of
Power is absolutely Vital if we are to move on a
progress as societies.
40
The Horizontal ideology
The concepts of a (N-G-R)PPCP
N=national; R= Regional; G= Global; PPCP0 Public, Private, Civil Partnership
• The “Horizontal Approach” to mental health
Policy
– Focuses on:
• The merger of the “top-down” approach
» &
• The “bottom-up” approach to policy
– And brings in corporate resources to make the
implementation phase happen.
– It means increasing the influence and control of civil
society on mental health issues
– It is a branch of a larger tree of “Open democracy”42
The creation of a horizontal Hybrid
STATE
Mental Health
MARKET
Civil Society
43
The creation of a horizontal
Hybrid
STATE
Mental Health
Civil Society
MARKET
44
PROVISION
Public
Public
Social democratic
welfare regime
(Nordic countries)
Private
Conservative welfare
regime (Partnership)
Civil Society
Services, prevention,
promotion programmes
(Partnership)
FUNDING
Awareness raising,
x
Liberal welfare regime services, prevention,
Private
(USA/ semi-developed promotion
countries)
x
programmes(Partnership)
x
Civil
Initiatives run and
Society
financed by the grass
root movements
45
Ministry of Health, Social affairs
& governm agencies
MH Objectives, National Health strategy
A Collaborative National Mental Health Project
Corporate resources
I
d
e
a
implementation
Driving force and motivation
Civil Society (Mental Health
ngo’s)
46
Inclusion of Civil Society (ICS)
The Horizontal ideology
Inclusion of Civil Society (ICS)
ALBANIA
Idea  strategy  Implementation
•Brief description of project:
–The project is aimed at empowering users and carers organisations and
facilitating their involvement in mental health policy and law
development and implementation.
–WHO is thought of as a catalyst of this process, a neutral agent aiming
to get both governmental officials and the national coalitions to work
together on a “horizontal” level aiming to recognise their communalities
rather than their differences and sharing power. That power sharing with
in the realm of an open democracy approach could lead to a vast change
in the national approach to mental health as well as in much more
empowerment of those using the mental health system.
48
Ministry of Health, Social affairs
& governm agencies
MH Objectives, National Health strategy
National partner
WHO
A Collaborative National Mental Health Project
implementation
Driving force and motivation
Civil Society (Mental Health
Coalition of ngo’s)
CS partners
49
50
51
52
53
54
55
56
57
A collection of European user stories
• A questionnarie based on the Helsinki Documents
• Around 30 qualatavtive questions catagorised in 7 groups:
–
–
–
–
–
–
–
Advocay and emmpowerment
Human rights
Stigma and discrimination
Treatment and services
Social inclusion
Selfhelp and recovery
Times of changes
• Users from 11 countries
• One story published on the WHO frontpage (one every month
starting October 2007)
• Results published in 2008 in 4 languages and 52 contries
58
Conclusion Norway
• 1st. Users and actors within civil society can
and will have more to say about mh policy
process and mh matters in general
–
–
–
–
Open democracy
Welfare changes
Market influence
Changing Health Systems
• 2nd. Governmental structures and IGOs do
want to have more input from those that
their “top-down” decisions are affecting
– Power
– Coalitions
– The academic and professional sphere
59
Conclusions Norway
• 3rd. The balancing paradigmal Power shift from
providers to users and carers as well as user
empowerment has started, but it is and will be a
long run process.
–
–
–
–
–
–
–
–
–
–
Politics
Lobbying
Strategies
Marketing
Coalitions
Cooperation
Communalities
Power
Fighting with soft power
Human Nature
• The general Issue of improved mental health
should unite us
60
Final remarks
• In my oppinion the transformation in mental health is a
branch on a larger tree of societical changes.
• Power from civilians to elected officials has been passed
for years in our democracies. Now we want to shape it
and share it.
• We should never forget the meaning of the word
“minister” deriving from ancient Greece
– = “minister” = the servant of the people
• Therefore in our “welfare” States are our mental health
professionals are the servants of our elected servants.
61
• It is hard to serve
Héðinn Unnsteinsson
62